Appointment Request Form
****Please allow for 3-5 business days for a returned call/email from our team! 

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Therapist you are wanting to schedule with *
Name *
If you are scheduling an appointment for a minor, please list their name here.
Phone Number *
Email Address *
Your Message *
What type of counseling services are you looking for? *
Required
What is the age of the potential client? *
Required
Are you looking for in-person or telemental health services? *
What is your preferred day for appointments? *
Check all that apply.
Required
What is your preferred time for appointments? *
Check all that apply.
Required
What is your household income range? *
Required
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